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  • Title: A risk, injury, failure, loss, and end-stage renal failure score-based trigger for renal replacement therapy and survival after cardiac surgery.
    Author: Schneider AG, Eastwood GM, Seevanayagam S, Matalanis G, Bellomo R.
    Journal: J Crit Care; 2012 Oct; 27(5):488-95. PubMed ID: 22480577.
    Abstract:
    PURPOSE: It is controversial whether all critically ill patients with risk, injury, failure, loss, and end-stage renal failure (RIFLE) F class acute kidney injury (AKI) should receive renal replacement therapy (RRT). We reviewed the outcome of open heart surgery patients with severe RIFLE-F AKI who did not receive RRT. MATERIALS AND METHODS: We identified all patients with AKI after cardiac surgery over 4 years and obtained baseline characteristics, intraoperative details, and in-hospital outcomes. We analyzed physiologic and biochemical features at RRT initiation or at peak creatinine if no RRT was provided. RESULTS: We reviewed 1504 patients. Of these, 137 (9.1%) developed postoperative AKI with 71 meeting RIFLE-F criteria and 23 (32.4% of RIFLE-F cases) not receiving RRT. Compared with RRT-treated RIFLE-F patients, "no-RRT" patients had lower Acute Physiology and Chronic Health Evaluation III scores, less intra-aortic balloon pump requirements, shorter intensive care stay, and a trend toward lower mortality. At peak RIFLE score, their urinary output, arterial pH, and Pao(2)/fraction of inspired oxygen ratio were all significantly higher. Their serum creatinine was also higher (304 vs 262 μmol/L; P = .02). Only 3 RIFLE-F no-RRT patients died in-hospital. Detailed review of cause and mode of death was consistent with non-RRT-preventable deaths. In contrast, 27 patients with RIFLE-R or RIFLE-I class received RRT. Compared with RRT-treated RIFLE-F patients, such RIFLE-R or RIFLE-I treated patients had a more severe presentation and higher mortality (51.8% vs 29.2%; P = .02). CONCLUSIONS: After cardiac surgery, RRT was typically applied to patients with the most severe clinical presentation irrespective of creatinine levels. A RIFLE score-based trigger for RRT is unlikely to improve patient survival.
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